Pennsylvania requires this cover report with supporting records before an employer or insurer has to pay for workers' compensation treatment. Providers file it within 10 days of starting treatment and at least monthly while treatment continues, attaching documentation such as history, diagnosis, findings, prognosis and return-to-work restrictions. Once services are properly billed and the LIBC-9 is received, the payer has 30 days to process the bill.
The treating health care provider completes the whole one-page form and attaches documentation suited to its provider type, whether physician, therapist, chiropractor, pharmacy, DME vendor, hospital, lab or imaging facility. The injured employee and the employer complete nothing on it.
Enter the employee's name, employer, insurer, WCAIS claim number, date of birth and date of injury, plus either the last digits of the Social Security number shown on the form or the WC ID number. Add the date of the report. The heading reminds providers that the form is filed with the employer or insurer according to the instructions printed on it.
Give the provider's name and address and a contact person with a telephone number for questions about the report or bill. The billing guidelines on page two require bills to be signed or typed with the provider's name and the name and signature to match, so the provider identified here should be the same one shown on the CMS-1500 or UB bill.
The printed instructions send the HCFA billing form and documentation to the employer, or to the insurer if the employer is insured. The LIBC-9 and its documentation are due within 10 days of starting treatment and at least monthly after, and the employer or insurer need not pay until it receives the report in the prescribed format.
Where pertinent, include the claimant's history, diagnosis, description of treatment and services, physical findings and prognosis, stating whether the claimant has recovered enough to return to work with or without limitations and any specific return-to-work restrictions. Bills for follow-up visits should include progress or office notes that support the diagnosis and the codes billed.
Bill on the HCFA/CMS 1500 or UB form, or successor forms, signed or typed with the provider's name, with name and signature matching. Cost-based providers submit detailed bills with service and revenue codes consistent with the charge master on file with the Bureau. Use the most appropriate and specific coding, and describe services in detail when using miscellaneous codes.
This section repeats the 10-day and monthly timing and lists suggested documentation by provider type: office notes for physicians, daily treatment notes with the physician referral for therapists, prescription details for pharmacies, HCPCS code and certificate of medical necessity for DME, ASA code and anesthesia record for anesthesia, and H&P, discharge summary and operative report for inpatient admissions.
Download the current version from the source each time; forms change without notice.
Workers' Compensation Medical Report Form
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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Within 10 days of commencing treatment and at least once a month afterward for as long as treatment continues. Each filing must be accompanied by documentation supporting the billing, and the employer or insurer does not have to pay for the treatment until the required report and records have been received.
No. The form states that providers may not charge for documentation supporting a claim for payment. A provider may charge its usual fee only for special reports that the employer or insurer specifically requests. All patient information must be submitted with the patient's knowledge and kept confidential by the employer or insurer.
Where pertinent, the history, diagnosis, treatment and services, physical findings and prognosis, including whether the claimant can return to work and any specific restrictions. Suggested attachments vary by provider: office notes for physicians, daily notes with the referral for therapists, reports for imaging, test results for labs, and H&P, discharge summary and operative report for inpatient admissions.
Yes. The Department of Labor & Industry posts both an interactive fillable PDF and a print version of the LIBC-9 on its BWC and OCR forms page. The interactive form is revision 09-22, and its second page holds the billing form guidelines and the medical report form guidelines.